FORWARD Bilateral Finger Thoracotomy Kit

A simple thoracostomy (also called finger thoracostomy or open thoracostomy) is a surgical procedure where a small incision is made in the chest wall to create an opening into the pleural space. Unlike tube thoracostomy, no chest tube is placed. The provider uses their finger to confirm entry into the pleural space, sweep for adhesions, and release trapped air or blood causing tension physiology. The site is then covered with a vented chest seal to allow continued drainage while preventing air ingress.

The procedure is called "finger" thoracostomy because the provider's gloved finger is inserted through the incision to tactilely confirm successful entry into the pleural space—something needle decompression cannot provide.

A thoracostomy kit is a pre-packaged collection of sterile supplies needed to perform thoracostomy (creating an opening into the chest cavity). Kits vary based on the type of thoracostomy:

• Finger/Simple Thoracostomy Kit: Contains scalpel, curved forceps/hemostat for blunt dissection, antiseptic prep, gauze, and chest seal
• Tube Thoracostomy Kit: Contains all the above plus a chest tube and one-way drainage valve

The FORWARD Bilateral kit is specifically designed for finger thoracostomy with duplicate instruments (2 scalpels, 2 forceps) to enable bilateral chest decompression—the only kit on the market with this capability.

"Thoracostomy" is the general term for any surgical opening into the chest cavity. There are three main types:

• Needle Thoracostomy: Inserting a needle/catheter through the chest wall (fastest but highest failure rate)
• Finger/Simple Thoracostomy: Making an incision and entering the pleural space with blunt dissection and finger confirmation, but NOT placing a tube
• Tube Thoracostomy (Chest Tube): Performing a finger thoracostomy AND then inserting a chest tube connected to a drainage system

So a "chest tube" (tube thoracostomy) includes finger thoracostomy as the first step—finger thoracostomy just stops before tube insertion. Finger thoracostomy is essentially a "chest tube without the tube."

Essential equipment for finger thoracostomy:

• Antiseptic prep (chlorhexidine or povidone-iodine)
• Scalpel (#10 blade) for skin incision
• Curved hemostat or Kelly clamp for blunt dissection through intercostal muscles and parietal pleura
• Sterile gloves for the finger sweep
• Gauze for hemorrhage control
• Chest seal (vented preferred) to cover the thoracostomy site

Optional: Skin marker for landmarks, local anesthetic if patient is conscious.

The FORWARD Bilateral kit includes all essential equipment with two complete instrument sets for bilateral procedures.

Bilateral finger thoracostomy is primarily performed in traumatic cardiac arrest to rapidly rule out tension pneumothorax as a reversible cause of arrest. The rationale:

• You can't reliably assess breath sounds during CPR
• Tension pneumothorax is a reversible cause of traumatic arrest
• Bilateral decompression eliminates the possibility on both sides simultaneously
• The procedure is faster than sequential needle attempts with confirmation

TCCC guidelines and many flight medicine protocols specifically recommend bilateral finger thoracostomy in traumatic arrest. The FORWARD Bilateral kit is the only pre-packaged kit designed specifically for this indication.

Finger thoracostomy offers several advantages over needle decompression:

• Tactile confirmation: You can FEEL that you've entered the pleural space—needle decompression provides no confirmation
• Lower failure rate: Needle decompression fails in 4-50% of cases due to inadequate needle length, catheter kinking, or clogging
• No catheter to kink or clog: The open thoracostomy stays patent
• Can evacuate hemothorax: Finger thoracostomy can release blood; needle catheters often clog with blood
• Enables chest tube if needed: Already have the incision if tube thoracostomy becomes indicated

The tradeoff is that finger thoracostomy is more invasive and requires expanded scope of practice authorization. Standard paramedics typically perform needle decompression; finger thoracostomy is usually reserved for flight/critical care providers.

Standard ground paramedics typically do NOT perform finger thoracostomy—it exceeds standard paramedic scope of practice in most states. Instead, standard paramedics perform needle thoracostomy (needle decompression).

Expanded scope providers who may perform finger thoracostomy include:

• Flight Paramedics (FP-C, CCEMTP)
• Flight Nurses (CFRN, CEN)
• Critical Care Paramedics
• Tactical Medics (TEMS)
• Military Medics (18D, 68W, SARC, PJ)
• Physicians and PAs

Authorization requires specific training, competency verification, and medical director approval. Always verify your scope of practice before performing any invasive procedure.

The FORWARD Bilateral kit is the only finger thoracostomy kit on the market with true bilateral capability:

• 2 scalpels (competitors include 1)
• 2 Rochester-Pean forceps (competitors include 1)
• Sterile instrument for each hemithorax—no cross-contamination
• Enables two providers to work simultaneously in arrest scenarios

Cost comparison: The FORWARD Bilateral kit costs $60. To get bilateral capability with competitor kits, you'd need to buy two kits (~$84+). You save $24+ while having everything in one package.

The FORWARD Bilateral kit includes the HALO Vented Chest Seal 2-Pack—one of the most trusted chest seals in tactical and EMS medicine. The vented design allows air and blood to escape while preventing air ingress, making it ideal for covering finger thoracostomy sites. With two seals included, you have one for each side in bilateral procedures.